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Gaetani M, Maratta C, Akinkugbe O, Ginter D, Baleilevuka-Hart M, Helmers A, Guerguerian AM, Mtaweh H. Invasive Group A Streptococcal Infections in Pediatric Critical Care: A Retrospective Cohort Study. Hosp Pediatr 2024:e2024007733. [PMID: 38864108 DOI: 10.1542/hpeds.2024-007733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/29/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND AND OBJECTIVE The reported rising global rates of invasive group A Streptococcus (iGAS) infection raise concern for disease related increase in critical illness and fatalities. An enhanced understanding of various presentations to health care and clinical course could improve early recognition and therapy in children with iGAS. The objective of this study was to describe the epidemiology of iGAS infections among children admitted to critical care. METHODS A retrospective cohort study of children admitted to the PICU at The Hospital for Sick Children, in Toronto, Canada, between March 2022 and June 2023. Eligible patients were 0 to 18 years, with a diagnosis of iGAS infection. We describe the proportion of children admitted to the PICU with iGAS over the study period, their clinical characteristics, the frequency and timing of therapies, discharge versus baseline function, and PICU mortality. RESULTS Among the 1820 children admitted to the PICU, 29 (1.6%) patients had iGAS infection. Of these 29 patients, 80% (n = 23) survived to hospital discharge. Patients who survived generally had favorable functional outcomes. Despite the high severity of illness and mortality described in this cohort, 61% returned to their baseline functional status by hospital discharge. CONCLUSIONS This is the first report of critically ill children with iGAS in Canada during the increased incidence reported worldwide. We describe the clinical course of iGAS infection in children admitted to PICU with access to advanced extracorporeal interventions. Though there is a high mortality rate in this cohort, those who survive have favorable outcomes.
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Affiliation(s)
- Melany Gaetani
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation; and
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Christina Maratta
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation; and
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Olugbenga Akinkugbe
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation; and
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Dylan Ginter
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Marica Baleilevuka-Hart
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Andrew Helmers
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Haifa Mtaweh
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
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Nakanishi R, Ozawa H, Toyota N, Mise M, Akutsu R, Fujita S. Acute Infectious Purpura Fulminans Complicated by Bacterial Translocation after Rectal Cancer Surgery: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:644. [PMID: 38674289 PMCID: PMC11051725 DOI: 10.3390/medicina60040644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024]
Abstract
The patient was a man in his 80s who had undergone laparoscopic anterior resection for rectal cancer. Bowel obstruction occurred on the third postoperative day but improved with a decompression tube by the fifth postoperative day. A high fever (in the 38 °C range) was also observed. Blood culture tests detected two sets of the gram-negative bacilli Klebsiella aerogenes within 24 h of collection. On the seventh postoperative day, the patient subsequently went into septic shock with disseminated intravascular coagulation (DIC). On the eighth postoperative day, the fingertips and toes became black, and the palms and dorsal surfaces of both feet were dark purple due to peripheral circulatory failure. This suggested acute infectious purpura associated with sepsis (acute infectious purpura fulminans (AIPF)). Intensive care was provided; however, the necrosis of both middle fingers worsened, both middle fingers were gangrenous, and the patient died on the thirtieth postoperative day. AIPF is rarely reported, especially in early-onset cases after elective surgery. We encountered a rare complication of bacterial translocation from postoperative bowel obstruction, leading to AIPF.
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Affiliation(s)
- Ryo Nakanishi
- Department of Colorectal Surgery, Tochigi Cancer Center, 4-9-13 Yohnan, Utsunomiya 320-0834, Japan; (H.O.); (N.T.); (M.M.); (R.A.); (S.F.)
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3
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Kikuchi-Ueda T, Maeno S, Gotoh Y, Ogura Y, Fujisaki R, Hayashi T. Complete genome sequences of 11 Streptococcus pneumoniae strains isolated from acute infectious purpura fulminans, sepsis, and pneumonia. Microbiol Resour Announc 2024; 13:e0077323. [PMID: 38132669 PMCID: PMC10868184 DOI: 10.1128/mra.00773-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/18/2023] [Indexed: 12/23/2023] Open
Abstract
The complete genome sequences of 11 Japanese Streptococcus pneumoniae isolates were determined by hybrid assembly of long and short reads, including two strains isolated from patients with acute infectious purpura fulminans, six strains from patients with sepsis, and three strains from patients with pneumonia.
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Affiliation(s)
- Takane Kikuchi-Ueda
- Department of Microbiology and Immunology, Teikyo University School of Medicine, Itabashi, Tokyo, Japan
| | - Shintaro Maeno
- Department of Bacteriology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Gotoh
- Department of Bacteriology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshitoshi Ogura
- Division of Microbiology, Department of Infectious Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Ryuichi Fujisaki
- Department of Sport and Medical Science, Faculty of Medical Technology, Teikyo University, Tokyo, Japan
| | - Tetsuya Hayashi
- Department of Bacteriology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
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Tew ZY, Johnson D, Louis G, Bhowmick K. Purpura fulminans in a hyposplenic patient arising from pneumococcal sinusitis. BMJ Case Rep 2023; 16:e253043. [PMID: 37460246 PMCID: PMC10357718 DOI: 10.1136/bcr-2022-253043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
We report a previously healthy woman in her 50s who presented with sepsis, rapidly progressive purpuric rash and disseminated intravascular coagulation. She was diagnosed with acute infective purpura fulminans due to invasive pneumococcal infection likely secondary to sinusitis. Our case report discusses our initial diagnostic uncertainty and approach in investigating and treating such a critically unwell patient.
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Affiliation(s)
- Zi Yi Tew
- Department of Anaesthesia, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Daniel Johnson
- Department of General Medicine, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
| | - Gerard Louis
- Department of Emergency Medicine, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Kaushik Bhowmick
- Department of Anaesthesia, West Suffolk NHS Foundation Trust, Bury Saint Edmunds, UK
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5
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Das DS, Mohanty RR, Behera A, Behera S. Purpura fulminans complicating scrub typhus and acute hepatitis E coinfection. BMJ Case Rep 2023; 16:e255790. [PMID: 37433688 PMCID: PMC10347465 DOI: 10.1136/bcr-2023-255790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Affiliation(s)
- Dhriti Sundar Das
- General Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Rashmi Ranjan Mohanty
- General Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Anupama Behera
- General Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Srikant Behera
- General Medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
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6
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Contou D, Béduneau G, Rabault C, Sonneville R, Marchalot A, Coudroy R, Roux D, Cour M, Massol J, Préau S, de Prost N. Skin biopsy in adult patients with meningococcal purpura fulminans: a multicenter retrospective cohort study. Crit Care 2023; 27:166. [PMID: 37122034 PMCID: PMC10150539 DOI: 10.1186/s13054-023-04461-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/25/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Neisseria meningitidis is the leading responsible bacterium of Purpura Fulminans (PF) accounting for two thirds of PF. Skin biopsy is a simple and minimally invasive exam allowing to perform skin culture and polymerase chain reaction (PCR) to detect Neisseria meningitidis. We aimed to assess the sensitivity of skin biopsy in adult patients with meningococcal PF. METHODS A 17-year multicenter retrospective cohort study including adult patients admitted to the ICU for a meningococcal PF in whom a skin biopsy with conventional and/or meningococcal PCR was performed. RESULTS Among 306 patients admitted for PF, 195 had a meningococcal PF (64%) with a skin biopsy being performed in 68 (35%) of them. Skin biopsy was performed in median 1 day after the initiation of antibiotic therapy. Standard culture of skin biopsy was performed in 61/68 (90%) patients and grew Neisseria meningitidis in 28 (46%) of them. Neisseria meningitidis PCR on skin biopsy was performed in 51/68 (75%) patients and was positive in 50 (98%) of them. Among these 50 positive meningococcal PCR, five were performed 3 days or more after initiation of antibiotic therapy. Finally, skin biopsy was considered as contributive in 60/68 (88%) patients. Identification of the meningococcal serogroup was obtained with skin biopsy in 48/68 (71%) patients. CONCLUSIONS Skin biopsy with conventional culture and meningococcal PCR has a global sensitivity of 88% and should be systematically considered in case of suspected meningococcal PF even after the initiation of antimicrobial treatment.
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Affiliation(s)
- Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-Colonel Prud'hon, 95100, Argenteuil, France.
| | - Gaëtan Béduneau
- Service de Médecine Intensive et Réanimation, Université UNIROUEN, UR 383, Centre Hospitalier Universitaire de Rouen, 37 Bd Gambetta, 76000, Rouen, France
| | - Charlotte Rabault
- Service de Médecine Intensive Réanimation, Hôpital Bichat-Claude Bernard (AP-HP), 46, rue Henri Huchard, 75877, Paris Cedex 18, France
- Service de Microbiologie, Hôpital Bichat-Claude Bernard (AP-HP), 46, rue Henri Huchard, 75877, Paris Cedex 18, France
| | - Romain Sonneville
- Service de Médecine Intensive Réanimation, Hôpital Bichat-Claude Bernard (AP-HP), 46, rue Henri Huchard, 75877, Paris Cedex 18, France
| | - Antoine Marchalot
- Service de Médecine Intensive et Réanimation, Centre Hospitalier de Dieppe, Av. Pasteur, 76202, Dieppe, France
| | - Rémi Coudroy
- Service de Médecine Intensive et Réanimation, Centre Hospitalier de Poitiers, 2 Rue de La Milétrie, 86000, Poitiers, France
| | - Damien Roux
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire Louis Mourier (AP-HP), 178 Rue des Renouillers, 92700, Colombes, France
| | - Martin Cour
- Service de Médecine Intensive et Réanimation, Centre Hospitalier de Lyon, Hospices Civils de Lyon, 5 Place d'Arsonval, 69437, Lyon Cédex 03, France
| | - Julien Massol
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire Cochin (AP-HP), 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Sébastien Préau
- Service de Médecine Intensive et Réanimation, Centre Hospitalier de Lille, 2 Av. Oscar Lambret, 59000, Lille, France
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, Hôpital Henri Mondor (AP-HP), Assistance Publique-Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France
- Groupe de Recherche Clinique CARMAS, Université Paris-Est, 94000, Créteil, France
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7
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Lin C, Li D, Hu B. Lower Limb Necrosis Secondary to Purpura Fulminans: A Case Report. J Burn Care Res 2023; 44:477-480. [PMID: 36548961 DOI: 10.1093/jbcr/irac186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Indexed: 12/24/2022]
Abstract
Purpura fulminans is a rare and rapidly progressive septic process characterized by the development of hemorrhagic and ecchymotic lesions and skin necrosis. In this work, we report a case of a 52-year-old woman admitted to the Department of Emergency due to progressive purpura. The physical examination demonstrated a decreased skin temperature, unpalpable dorsalis pedis arteries, and ecchymoses covering both lower extremities. Laboratory tests indicated disseminated intravascular coagulation with prolonged activated partial thromboplastin time (APTT), low prothrombin time (PT), elevated d-dimer levels, and a low platelet count. A diagnosis of purpura fulminans was made, and steroids, therapeutic plasma exchange and empiric therapy, including antibiotic and anticoagulation therapy, were initiated immediately. Our treatment resulted in a good and sustained clinical response, as evidenced by the receding of blood blisters and the normalization of the patient's coagulation factors, but bilateral below-knee amputation was inevitable. Finally, the patient recovered well and was discharged home without any complications other than amputation.
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Affiliation(s)
- Chuangqiang Lin
- Department of Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, China
| | - Dongxin Li
- Department of Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Bei Hu
- Department of Emergency Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
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8
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Goodall RJ, Roberts J, Correia MD, Frew Q, Barnes D, Dziewulski P, Shelley O, El-Muttardi N. Management of purpura fulminans skin loss at a regional burns centre: Sixteen-year experience. J Plast Reconstr Aesthet Surg 2023; 79:23-29. [PMID: 36842284 DOI: 10.1016/j.bjps.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Purpura fulminans (PF) is a rare syndrome of cutaneous purpura which is the consequence of severe circulatory shock causing intravascular thrombosis, haemorrhagic necrosis, and consequent tissue loss. The aim of this study was to present our 16-year experience of managing PF in a regional burns centre. METHODS We performed a single-centre retrospective case series of all patients admitted to the St Andrews Burns Centre at Broomfield Hospital, Chelmsford, Essex, UK, between June 2006 and July 2022 with a diagnosis of PF. Data were extracted by retrospectively searching hospital case notes. RESULTS Thirteen individuals were identified [five children (mean age 5, range 1-14) and eight adults (mean age 39, range 24-54)]. The total body surface area of cutaneous necrosis ranged from 5% to 80%, with a mean of 27.2%. Patients were treated with an established surgical sequence of total wound debridement and immediate coverage with a cadaveric allograft, followed by staged wound autografting. The mean time from disease onset to wound autografting was 37.3 days (range 20-64 days). Eight individuals (61.6%) required major amputation of at least one limb (proximal to the ankle or wrist joint). Only one mortality (of 80% total body surface area skin loss) was observed in the identified cohort. CONCLUSIONS The large body surface areas often involved in PF cases make management of these wounds well suited for burns centres, wherein established facilities and multidisciplinary teams exist that are familiar with managing large cutaneous burns. We provide a suggested algorithm to aid the management of PF.
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Affiliation(s)
- R J Goodall
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK.
| | - J Roberts
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - M D Correia
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - Q Frew
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - D Barnes
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - P Dziewulski
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - O Shelley
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - N El-Muttardi
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
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9
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Epidemiology and Clinical Burden of Meningococcal Disease in France: Scoping Review. J Clin Med 2023; 12:jcm12030849. [PMID: 36769498 PMCID: PMC9917955 DOI: 10.3390/jcm12030849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/03/2023] [Accepted: 01/14/2023] [Indexed: 01/25/2023] Open
Abstract
Invasive meningococcal disease (IMD) remains a significant health concern due to its unpredictable nature and its rapid progression. Even if occurrence of IMD is strictly monitored by a national surveillance network, no information on long-term sequelae is reported, making it difficult to assess the entire clinical burden of IMD in France. The aim of this scoping review was to analyze the epidemiology and the clinical burden of IMD in France by reporting the main epidemiological parameters, and by describing the clinical consequences and the care pathway of patients. The process of the review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension to the Scoping Reviews guidelines. In France, the incidence of IMD cases has been fluctuating over time, characterized by an overall downward trend linked to a decrease in Sg B cases and the introduction of mandatory vaccination against Sg C. Sg W cases increased in recent years (from 5% to 21% in 2019). The case fatality rate remained constant (6-12.9%). The most frequently reported sequelae were severe neurological disorder, epilepsy, and anxiety. However, data on sequelae and care pathways were scarce. Further research should concentrate on providing robust identification of sequelae and the subsequent impact on quality of life, as well as on the organization of optimal care and support for patients and their families.
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10
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Ishii J, Haratake D, Ito M, Shime N. Purpura fulminans due to Rickettsia japonica. QJM 2022; 115:758-759. [PMID: 35976146 DOI: 10.1093/qjmed/hcac188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- J Ishii
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - D Haratake
- Department of General Internal Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - M Ito
- Department of General Internal Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
| | - N Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan
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11
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Lundy A, Claudinon A, Tirolien JA, Plantefève G, Contou D. Purpura fulminans due to Enterococcus cecorum in an asplenic patient. IDCases 2022; 29:e01522. [PMID: 35669525 PMCID: PMC9163486 DOI: 10.1016/j.idcr.2022.e01522] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022] Open
Abstract
Enterococcus cecorum was initially isolated from the intestine of poultry and is an uncommon cause of human infection. We report here what we believe to be the first case of overwhelming post-splenectomy infection (OPSI) with purpura fulminans due to Enterococcus cecorum in a 51-year-old man. As opposed to other enterococci, Enterococcus cecorum remains susceptible to third-generation cephalosporin which is the first line empirical antibiotic therapy for both patients with purpura fulminans and asplenic patients with sepsis. Despite adequate antibiotic therapy, evolution in the intensive care unit (ICU) was overwhelming with death occurring 10 h after ICU admission.
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Affiliation(s)
- Alexia Lundy
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-Colonel Prud'hon, 95100 Argenteuil, France
| | - Aurore Claudinon
- Service de microbiologie, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-Colonel Prud'hon, 95100 Argenteuil, France
| | - Jo-Anna Tirolien
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-Colonel Prud'hon, 95100 Argenteuil, France
| | - Gaëtan Plantefève
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-Colonel Prud'hon, 95100 Argenteuil, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-Colonel Prud'hon, 95100 Argenteuil, France
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12
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Prevalence and clinical features of secondary skin lesions in septic patients with bloodstream infections. Eur J Clin Microbiol Infect Dis 2022; 41:779-786. [PMID: 35320429 DOI: 10.1007/s10096-022-04431-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/14/2022] [Indexed: 11/03/2022]
Abstract
Cutaneous manifestations developed in the course of sepsis are poorly documented in the medical literature beyond those related to specific pathogens or classical clinical pictures such as purpura fulminans or ecthyma gangrenosum. The objective of this study was to determine the overall prevalence of sepsis-related skin findings and evaluate their possible impact on the prognosis of septic patients. Single-centre, retrospective study of septic patients with documented bloodstream infections admitted in a tertiary hospital during 2019. Primary skin and soft tissue infections, and non-sepsis-related skin conditions diagnosed during hospital admission were excluded. Unselected sample of 320 episodes of sepsis in 265 patients. Secondary skin lesions were documented in 57 sepsis episodes (17.8%) in 47 patients. Purpura (petechiae/ecchymosis) was the most frequent cutaneous finding in septic patients (35.5%), with non-acral involvement in more than one-third of the episodes (38.5%), followed by skin and soft tissue erythema/oedema (25.8%) and maculopapular rashes (11.3%). Secondary skin lesions occurred more frequently in sepsis of respiratory (p = 0.027) and skin and soft tissue (p = 0.018) origin, as well as in sepsis caused by Pseudomonas aeruginosa and Stenotrophomonas maltophilia (p = 0.001). Mean hospital stay was 38.58 days and sepsis-related mortality 21.1%. Our results suggest that cutaneous involvement in the course of sepsis is frequent, with purpura being the main clinical sign. The semiology described in this study, easily identifiable by non-dermatologists, should alert clinicians to the potential unfavourable course of these patients.
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13
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Contou D, Urbina T, de Prost N. Understanding purpura fulminans in adult patients. Intensive Care Med 2022; 48:106-110. [PMID: 34846563 DOI: 10.1007/s00134-021-06580-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/08/2021] [Indexed: 01/15/2023]
Affiliation(s)
- Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, Rue du Lieutenant-Colonel Prud'hon, 95100, Argenteuil, France.
| | - Tomas Urbina
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, Groupe de Recherche CARMAS, Centre Hospitalier Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France
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14
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Williamson SJ, Ruiz-Gaviria R. Pneumococcal purpura fulminans in a 25-year-old patient with liver cirrhosis due to autoimmune hepatitis. IDCases 2022; 30:e01610. [PMID: 36061139 PMCID: PMC9429787 DOI: 10.1016/j.idcr.2022.e01610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/19/2022] [Indexed: 11/29/2022] Open
Abstract
Purpura fulminans (PF) is a skin disorder with high morbidity and mortality which is characterized by microvascular thrombosis and development of hemorrhagic necrosis. PF can be caused by acute infection, most commonly due to Neisseria meningitidis, followed by Streptococcus pneumoniae. Prior reports describe cases of pneumococcal PF occurring in patients with asplenia or hyposplenia, though cases have also been reported in otherwise healthy adults without known splenic disease. Herein, we report a young adult patient with cirrhosis due to autoimmune hepatitis who had not received pneumococcal vaccination and developed rapidly progressive fatal S. pneumoniae sepsis with PF.
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15
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Free flap for lower limb salvage in infectious purpura fulminans. ANN CHIR PLAST ESTH 2021; 66:420-428. [PMID: 34782172 DOI: 10.1016/j.anplas.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/10/2021] [Accepted: 10/18/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Infectious purpura fulminans is a disabling disease often leading to amputations. Free flaps preserve limb length, covering exposed areas. We examined the efficacy of free flaps for lower limb salvage in infectious purpura fulminans survivors by evaluating surgical management, walking ability and quality of life. METHODS This single-center, observational, descriptive, retrospective study was conducted in from 2016 to 2019. Adult purpura fulminans survivors who received a free flap for lower limb salvage were included. Patient characteristics and data on surgical management and rehabilitation were collected. Quality of life (SF-36 questionnaire), limb function and walking ability were later evaluated post-surgically. RESULTS The 6 patients included, mean age 38 years, had all required amputations. Nine free flaps were performed to cover important structures in 7 cases and for stump resurfacing in 2. All flaps were successful. Patients resumed walking at a mean of 204±108 days after the onset of purpura fulminans. Post-surgical evaluation was performed at a mean of 30±9.3 months. Five patients required secondary revision. All were independent for the activities of daily living. Mean physical component score was 37.6±9.4 and mental component score was 44.6±13.2 (minimum 0, maximum 100). CONCLUSIONS Use of the free flap in patients with infectious purpura fulminans, after multidisciplinary reflection, is an appropriate procedure that preserves limb length. In spite of secondary complications, preservation of limb length enables patients to resume walking, with relatively good independence and quality of life.
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Contou D, de Prost N. Clinical phenotype and outcomes of pneumococcal versus meningococcal purpura fulminans: a multicenter retrospective cohort study. Crit Care 2021; 25:386. [PMID: 34763715 PMCID: PMC8582106 DOI: 10.1186/s13054-021-03812-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/04/2021] [Indexed: 02/03/2023] Open
Affiliation(s)
- Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-Colonel Prudhon, 95100, Argenteuil, France.
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, Groupe de Recherche CARMAS, Centre Hospitalier Universitaire Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51, avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France
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17
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Manriquez V, Nivoit P, Urbina T, Echenique-Rivera H, Melican K, Fernandez-Gerlinger MP, Flamant P, Schmitt T, Bruneval P, Obino D, Duménil G. Colonization of dermal arterioles by Neisseria meningitidis provides a safe haven from neutrophils. Nat Commun 2021; 12:4547. [PMID: 34315900 PMCID: PMC8316345 DOI: 10.1038/s41467-021-24797-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/30/2021] [Indexed: 01/07/2023] Open
Abstract
The human pathogen Neisseria meningitidis can cause meningitis and fatal systemic disease. The bacteria colonize blood vessels and rapidly cause vascular damage, despite a neutrophil-rich inflammatory infiltrate. Here, we use a humanized mouse model to show that vascular colonization leads to the recruitment of neutrophils, which partially reduce bacterial burden and vascular damage. This partial effect is due to the ability of bacteria to colonize capillaries, venules and arterioles, as observed in human samples. In venules, potent neutrophil recruitment allows efficient bacterial phagocytosis. In contrast, in infected capillaries and arterioles, adhesion molecules such as E-Selectin are not expressed on the endothelium, and intravascular neutrophil recruitment is minimal. Our results indicate that the colonization of capillaries and arterioles by N. meningitidis creates an intravascular niche that precludes the action of neutrophils, resulting in immune escape and progression of the infection.
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Affiliation(s)
- Valeria Manriquez
- Pathogenesis of Vascular Infections unit, INSERM, Institut Pasteur, Paris, France
| | - Pierre Nivoit
- Pathogenesis of Vascular Infections unit, INSERM, Institut Pasteur, Paris, France
| | - Tomas Urbina
- Pathogenesis of Vascular Infections unit, INSERM, Institut Pasteur, Paris, France
| | | | - Keira Melican
- Pathogenesis of Vascular Infections unit, INSERM, Institut Pasteur, Paris, France
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Patricia Flamant
- Experimental Neuropathology Unit, Institut Pasteur, Paris, France
| | | | - Patrick Bruneval
- Service d'Anatomie Pathologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Dorian Obino
- Pathogenesis of Vascular Infections unit, INSERM, Institut Pasteur, Paris, France.
| | - Guillaume Duménil
- Pathogenesis of Vascular Infections unit, INSERM, Institut Pasteur, Paris, France.
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18
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Pulido-Pérez A, Bergón-Sendín M, Suárez-Fernández R, Muñoz-Martín P, Bouza E. Skin and sepsis: contribution of dermatology to a rapid diagnosis. Infection 2021; 49:617-629. [PMID: 33860474 DOI: 10.1007/s15010-021-01608-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/19/2021] [Indexed: 11/24/2022]
Abstract
In patients who develop sepsis, whether due to primary, secondary or metastatic lesions, the skin is frequently affected. However, there are unresolved aspects regarding the general clinical manifestations in the skin or the prognosis and/or therapeutic implications. The main challenge in the approach to sepsis is its early diagnosis and management. In this review, we address the sepsis-skin relationship and the potential impact of early dermatological intervention on the septic patient through ten basic questions. We found little evidence of the participation of the dermatologist in sepsis alert programs. There are early skin changes that may alert clinicians on a possible sepsis, such as skin mottling or variations in acral skin temperature. In addition, the skin is an accessible and highly cost-effective tissue for etiological studies of some forms of sepsis (e.g., meningococcal purpura) and its involvement defines the prognosis of certain patients (e.g., infective endocarditis).
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Affiliation(s)
- A Pulido-Pérez
- Department of Dermatology, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo 46, 28007, Madrid, Spain. .,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.
| | - M Bergón-Sendín
- Department of Dermatology, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo 46, 28007, Madrid, Spain.,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - R Suárez-Fernández
- Department of Dermatology, Hospital General Universitario Gregorio Marañón, C/Doctor Esquerdo 46, 28007, Madrid, Spain.,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - P Muñoz-Martín
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - E Bouza
- CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Madrid, Spain.,Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Biomédica Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Meini S, Sozio E, Bertolino G, Sbrana F, Ripoli A, Pallotto C, Viaggi B, Andreini R, Attanasio V, Rescigno C, Atripaldi L, Leonardi S, Bernardo M, Tascini C. D-Dimer as Biomarker for Early Prediction of Clinical Outcomes in Patients With Severe Invasive Infections Due to Streptococcus Pneumoniae and Neisseria Meningitidis. Front Med (Lausanne) 2021; 8:627830. [PMID: 33937280 PMCID: PMC8081958 DOI: 10.3389/fmed.2021.627830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/23/2021] [Indexed: 12/12/2022] Open
Abstract
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection; no current clinical measure adequately reflects the concept of dysregulated response. Coagulation plays a pivotal role in the normal response to pathogens (immunothrombosis), thus the evolution toward sepsis-induced coagulopathy could be individuate through coagulation/fibrinolysis-related biomarkers. We focused on the role of D-dimer assessed within 24 h after admission in predicting clinical outcomes in a cohort of 270 patients hospitalized in a 79 months period for meningitis and/or bloodstream infections due to Streptococcus pneumoniae (n = 162) or Neisseria meningitidis (n = 108). Comparisons were performed with unpaired t-test, Mann-Whitney-test or chi-squared-test with continuity correction, as appropriate, and multivariable logistic regression analysis was performed with Bayesian model averaging. In-hospital mortality was 14.8% for the overall population, significantly higher in S. pneumoniae than in N. meningitidis patients: 19.1 vs. 8.3%, respectively (p = 0.014). At univariable logistic regression analysis the following variables were significantly associated with in-hospital mortality: pneumococcal etiology, female sex, age, ICU admission, SOFA score, septic shock, MODS, and D-dimer levels. At multivariable analysis D-dimer showed an effect only in N. meningitidis subgroup: as 500 ng/mL of D-dimer increased, the probability of unfavorable outcome increased on average by 4%. Median D-dimer was significantly higher in N. meningitidis than in S. pneumoniae patients (1,314 vs. 1,055 ng/mL, p = 0.009). For N. meningitidis in-hospital mortality was 0% for D-dimer <500 ng/mL, very low (3.5%) for D-dimer <7,000 ng/mL, and increased to 26.1% for D-dimer >7,000 ng/mL. Kaplan-Meier analysis of in-hospital mortality showed for N. meningitidis infections a statistically significant difference for D-dimer >7,000 ng/mL compared to values <500 ng/mL (p = 0.021) and 500-3,000 ng/mL (p = 0.002). For S. pneumoniae the mortality risk resulted always high, over 10%, irrespective by D-dimer values. In conclusion, D-dimer is rapid to be obtained, at low cost and available everywhere, and can help stratify the risk of in-hospital mortality and complications in patients with invasive infections due to N. meningitidis: D-dimer <500 ng/mL excludes any further complications, and a cut-off of 7,000 ng/mL seems able to predict a significantly increased mortality risk from much <10% to over 25%.
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Affiliation(s)
- Simone Meini
- Internal Medicine Unit, Felice Lotti Hospital of Pontedera, Azienda Unità Sanitaria Locale Toscana Nord-Ovest, Pisa, Italy
| | - Emanuela Sozio
- Infectious Disease Unit, Department of Medicine, University of Udine, Udine, Italy
| | | | | | | | - Carlo Pallotto
- Infectious Diseases Unit 1, Santa Maria Annunziata Hospital, Azienda Unità Sanitaria Locale Toscana Centro, Florence, Italy.,Section of Infectious Diseases, Department of Medicine, University of Perugia, Perugia, Italy
| | - Bruno Viaggi
- Neuro Intensive Care Unit, Department of Anesthesiology, Careggi University Hospital, Florence, Italy
| | - Roberto Andreini
- Internal Medicine Unit, Felice Lotti Hospital of Pontedera, Azienda Unità Sanitaria Locale Toscana Nord-Ovest, Pisa, Italy
| | - Vittorio Attanasio
- First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Carolina Rescigno
- First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Luigi Atripaldi
- Central Laboratory, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Silvia Leonardi
- Central Laboratory, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Mariano Bernardo
- Central Laboratory, Azienda Ospedaliera dei Colli, Naples, Italy
| | - Carlo Tascini
- Infectious Disease Unit, Department of Medicine, University of Udine, Udine, Italy.,First Division of Infectious Diseases, Cotugno Hospital, Azienda Ospedaliera dei Colli, Naples, Italy
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20
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Abstract
: Coronavirus disease 2019 (COVID-19) was officially declared as a pandemic on March 11, 2020. Although most patients with COVID-19 manifest fever and respiratory tract symptoms, extrapulmonary and atypical presentations, such as gastrointestinal, neurologic, and cardiovascular involvement as well as thromboembolic events have been reported amongst COVID-19 patients. Herein, we aim to describe a COVID-19 patient who progressed to purpura fulminans.
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21
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Contou D, Canoui-Poitrine F, Coudroy R, Préau S, Cour M, Barbier F, Terzi N, Schnell G, Galbois A, Zafrani L, Zuber B, Ehrmann S, Gelisse E, Colling D, Schmidt M, Jaber S, Conia A, Sonneville R, Colin G, Guérin L, Roux D, Jochmans S, Kentish-Barnes N, Audureau E, Layese R, Alves A, Ouedraogo R, Brun-Buisson C, Mekontso Dessap A, de Prost N, Barbier F, Bazire A, Béduneau G, Bellec F, Beuret P, Blanc P, Bruel C, Brun-Buisson C, Colin G, Colling D, Conia A, Coudroy R, Cour M, Contou D, Daviaud F, Das V, Dellamonica J, Demars N, Ehrmann S, Galbois A, Gelisse E, Grouille J, Guérin L, Guérot E, Jaber S, Jannière C, Jochmans S, Jozwiak M, Kalfon P, Kimmoun A, Lautrette A, Layese R, Lemarié J, Le Moal C, Lenclud C, Lerolle N, Leroy O, Marchalot A, Mégarbane B, Mekontso Dessap A, de Montmollin E, Pène F, Pichereau C, Plantefève G, Préau S, Preda G, de Prost N, Quenot JP, Ricome S, Roux D, Sauneuf B, Schmidt M, Schnell G, Sonneville R, Tadié JM, Tandjaoui Y, Tchir M, Terzi N, Valette X, Zafrani L, Zuber B. Long-term Quality of Life in Adult Patients Surviving Purpura Fulminans: An Exposed-Unexposed Multicenter Cohort Study. Clin Infect Dis 2020; 69:332-340. [PMID: 30335142 DOI: 10.1093/cid/ciy901] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 10/11/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Long-term health-related quality of life (HR-QOL) of patients surviving the acute phase of purpura fulminans (PF) has not been evaluated. METHODS This was a French multicenter exposed-unexposed cohort study enrolling patients admitted in 55 intensive care units (ICUs) for PF from 2010 to 2016. Adult patients surviving the acute phase of PF (exposed group) were matched 1:1 for age, sex, and Simplified Acute Physiology Score II with septic shock survivors (unexposed group). HR-QOL was assessed during a phone interview using the 36-Item Short-Form Health Survey (SF-36) questionnaire, the Hospital Anxiety and Depression (HAD) scale, the Impact of Event Scale-Revised (IES-R), and the activity of daily living (ADL) and instrumental ADL (IADL) scales. The primary outcome measure was the physical component summary (PCS) of the SF-36 questionnaire. RESULTS Thirty-seven survivors of PF and 37 of septic shock were phone-interviewed at 55 (interquartile range [IQR], 35-83) months and 44 (IQR, 35-72) months, respectively, of ICU discharge (P = .23). The PCS of the SF-36 was not significantly different between exposed and unexposed patients (median, 47 [IQR, 36-53] vs 54 [IQR, 36-57]; P = .18). There was also no significant difference between groups regarding the mental component summary of the SF-36, and the HAD, IES-R, ADL and IADL scales. Among the 37 exposed patients, those who required limb amputation (n = 12/37 [32%]) exhibited lower PCS (34 [IQR, 24-38] vs 52 [IQR, 42-56]; P = .001) and IADL scores (7 [IQR, 4-8] vs 8 [IQR, 7-8]; P = .021) compared with nonamputated patients. CONCLUSIONS Long-term HR-QOL does not differ between patients surviving PF and those surviving septic shock unrelated to PF. Amputated patients have an impaired physical HR-QOL but a preserved mental health. CLINICAL TRIALS REGISTRATION NCT03216577.
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Affiliation(s)
- Damien Contou
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil.,Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, Argenteuil.,Groupe de Recherche Clinique Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Université Paris Est-Créteil
| | - Florence Canoui-Poitrine
- Service de Santé Publique, Hôpital Henri-Mondor, AP-HP.,Université Paris-Est, Clinical Epidemiology and Aging Unit, Créteil
| | - Rémi Coudroy
- Service de réanimation médicale, Centre Hospitalier Universitaire de Poitiers, Institut National de la Santé et de la Recherche Médicale (INSERM) Centre d'Investigation Clinique 1402, Acute Lung Injury and Ventilation Group, Université de Poitiers
| | - Sébastien Préau
- Service de réanimation médicale, Centre hospitalier régional universitaire de Lille
| | - Martin Cour
- Réanimation Médicale, Hospices Civils de Lyon-Groupement Hospitalier Edouard Herriot
| | - François Barbier
- Service de réanimation médicale, Centre Hospitalier Régional d'Orléans
| | - Nicolas Terzi
- Service de réanimation médicale, Centre Hospitalier Universitaire Grenoble Alpes, La Tronche
| | - Guillaume Schnell
- Service de réanimation médico-chirurgicale, Groupe Hospitalier Le Havre
| | - Arnaud Galbois
- Service de réanimation médico-chirurgicale, Hôpital Claude Galien, Quincy-sous-Sénart
| | - Lara Zafrani
- Service de réanimation médicale, Hôpital Saint-Louis, AP-HP, Paris
| | - Benjamin Zuber
- Service de réanimation médico-chirurgicale, Centre Hospitalier André Mignot, Le Chesnay
| | - Stephan Ehrmann
- Service de Réanimation Médicale, Centre Hospitalier Régional Universitaire, Tours
| | - Elodie Gelisse
- Service de réanimation médico-chirurgicale, Centre Hospitalier Universitaire de Reims
| | - Delphine Colling
- Service de réanimation médico-chirurgicale, Centre hospitalier de Roubaix
| | - Matthieu Schmidt
- Service de Réanimation médicale, Centre Hospitalier Universitaire Pitié-Salpétrière, AP-HP, Paris
| | - Samir Jaber
- Service de Réanimation médico-chirurgicale, Centre Hospitalier Universitaire de Montpellier
| | - Alexandre Conia
- Service de Réanimation médico-chirurgicale, Centre Hospitalier de Chartres
| | - Romain Sonneville
- Service de Réanimation Médicale, Hôpital Bichat Claude Bernard, AP-HP, Paris
| | - Gwenhaël Colin
- Service de réanimation médico-chirurgicale, Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon
| | - Laurent Guérin
- Service de réanimation médico-chirurgicale, Hôpital Ambroise Paré, Boulogne-Billancourt
| | - Damien Roux
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Universitaire Louis Mourier, AP-HP, Colombes
| | | | | | - Etienne Audureau
- Service de Santé Publique, Hôpital Henri-Mondor, AP-HP.,Université Paris-Est, Clinical Epidemiology and Aging Unit, Créteil
| | - Richard Layese
- Service de Santé Publique, Hôpital Henri-Mondor, AP-HP.,Université Paris-Est, Clinical Epidemiology and Aging Unit, Créteil
| | - Aline Alves
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil
| | - Rachida Ouedraogo
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil
| | - Christian Brun-Buisson
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil
| | - Armand Mekontso Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil.,Groupe de Recherche Clinique Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Université Paris Est-Créteil
| | - Nicolas de Prost
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil.,Groupe de Recherche Clinique Cardiovascular and Respiratory Manifestations of Acute lung injury and Sepsis (CARMAS), Université Paris Est-Créteil
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Djurdjevic N, Taweesedt PT, Paulson M, LaNou A, Radovanovic M, Patel JN, Veselinovic M, McDermott WR, Dumic I. Septic Shock and Purpura Fulminans Due to Streptococcus pneumoniae Bacteremia in an Unvaccinated Immunocompetent Adult: Case Report and Review. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923266. [PMID: 32513908 PMCID: PMC7304654 DOI: 10.12659/ajcr.923266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Despite proven efficacy of vaccinations against Streptococcus pneumoniae in preventing infection, only 70% of eligible individuals receive the vaccine in the United States. Pneumococcal bacteremia represents a form of invasive pneumococcal disease and is associated with high mortality, especially in immunocompromised patients and the elderly. Purpura fulminans is a rare complication and manifestation of disseminated intravascular coagulation and sepsis. It is exceedingly rare in the setting of pneumococcal bacteremia, particularly in immunocompetent individuals. CASE REPORT We report a generally healthy 67-year-old male with schizophrenia who refused pneumococcal vaccination. He had an intact and functional spleen with a functional immune system. The patient presented with fever and diarrhea. He subsequently progressed to develop purpura fulminans and septic shock due to S. pneumoniae bacteremia. Despite an extensive search for the primary source of infection, none could not be identified. Due to timely initiation of appropriate antibiotic therapy and aggressive supportive care in an intensive care unit, he recovered despite multi-organ failure that developed throughout his hospitalization. CONCLUSIONS We present a rare manifestation of a potentially preventable disease and emphasize the importance of pneumococcal vaccination in order to decrease the risk of developing invasive pneumococcal disease. Furthermore, we discuss etiology, diagnosis, differential diagnosis, and evidence-based management of purpura fulminans and invasive pneumococcal disease with a literature review. Purpura fulminans due to S. pneumoniae is exceedingly rare in immunocompetent patients and an unusual clinical manifestation of pneumococcal bacteremia.
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Affiliation(s)
| | | | | | - Abigail LaNou
- Mayo Clinic, Alix School of Medicine, Rochester, MN, USA
| | | | - Janki N Patel
- Mayo Clinic, Alix School of Medicine, Rochester, MN, USA
| | | | | | - Igor Dumic
- Mayo Clinic, Alix School of Medicine, Rochester, MN, USA
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Ou S, Wang X, Huang Y, Zhu YT, Wu ML, Zheng XR, Liu CT. [Acute fever with rash, necrosis, and bullae in both lower extremities in a 12-year-old girl]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22:651-655. [PMID: 32571467 PMCID: PMC7390209 DOI: 10.7499/j.issn.1008-8830.2002079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/07/2020] [Indexed: 06/11/2023]
Abstract
A girl, aged 12 years, was admitted due to fever and rash for 3 days. The child developed recurrent high fever and rash on both lower extremities 3 days before, and the rash on left lower extremity quickly merged into a patch within 24 hours, with hemorrhage and necrosis in black and purple, large vesicles, and blisters in the center. Laboratory examination showed a reduction in platelet count and significant increases in fibrinogen and D-dimer during the course of the disease. The child was diagnosed with purpura flulminans. She was given meropenem combined with linezolid for anti-infection, injection of gamma globulin for immunoregulation, and low-molecular-weight heparin for anticoagulation. The fluid in the rash blisters was drawn and the wound was treated to prevent infection. The child's temperature returned to normal, with improvement in gangrene. She was discharged after platelet count, fibrinogen, and D-dimer had returned to normal. Purpura fulminans is a rare thrombotic hemorrhagic disease with rapid progression and is commonly seen in children. Without timely treatment, it may cause severe sequelae with high disability and mortality rates. Anti-infection, correction of coagulation function, and local management of gangrene skin are of great importance during treatment.
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Affiliation(s)
- Shuang Ou
- Department of Pediatrics, Xiangya Hospital of Central South University, Changsha 410008, China.
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24
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Contou D, Coudroy R, Colin G, Tadié JM, Cour M, Sonneville R, Mekontso Dessap A, de Prost N. Pneumococcal purpura fulminans in asplenic or hyposplenic patients: a French multicenter exposed-unexposed retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:68. [PMID: 32102696 PMCID: PMC7045371 DOI: 10.1186/s13054-020-2769-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/07/2020] [Indexed: 02/07/2023]
Abstract
Background Pneumococcal infections remain the main cause of overwhelming post-splenectomy infections, and purpura fulminans may develop in almost 20% of patients with overwhelming post-splenectomy infection. We aimed at describing the impact of asplenia/hyposplenia on the clinical features and the outcomes of adult patients admitted to the intensive care unit (ICU) for pneumococcal purpura fulminans. Methods A 17-year national multicenter retrospective cohort study included adult patients admitted to 55 French ICUs for an infectious purpura fulminans from 2000 to 2016. Patients with pneumococcal purpura fulminans were analyzed according to the absence or presence of asplenia/hyposplenia. Results Among the 306 patients admitted to the ICU for purpura fulminans, 67 (22%) had a pneumococcal purpura fulminans, of whom 34 (51%) had asplenia (n = 29/34, 85%) or hyposplenia (n = 5/34, 15%) and 33 (49%) had eusplenia. The prevalence of pneumococcal purpura fulminans was seven times higher in asplenic/hyposplenic patients compared to eusplenic patients with purpura fulminans (n = 34/39, 87% vs. n = 33/267, 12%; p < 0.001). The median time interval between the occurrence of asplenia/hyposplenia and ICU admission was 20 [9–32] years. Pneumococcal vaccine coverage was 35% in asplenic/hyposplenic patients. Purpura was more frequently reported before ICU admission in asplenic/hyposplenic patients (n = 25/34, 73% vs. n = 13/33, 39%; p = 0.01). The rate of bacteremia did not differ between asplenic/hyposplenic and eusplenic patients (n = 31/34, 91% vs n = 27/33, 82%; p = 0.261). SAPS II (60 ± 14 vs. 60 ± 18; p = 0.244) and SOFA (13 [1–5] vs. 14 [1–4, 6]; p = 0.48) scores did not differ between asplenic/hyposplenic and eusplenic patients. There were no significant differences between asplenic/hyposplenic and eusplenic patients regarding the rate of limb amputation (n = 9/34, 26% vs. 15/33, 45%; p = 0.11) and hospital mortality (n = 20/34, 59% vs. n = 15/33, 45%; p = 0.27). Conclusions Half of pneumococcal purpura fulminans episodes occurred in asplenic or hyposplenic patients. Pneumococcal vaccine coverage was reported in one third of asplenic/hyposplenic patients. Half of pneumococcal purpura fulminans episodes occurred more than 20 years after splenectomy. Outcomes of pneumococcal purpura fulminans did not show significant differences between patients with or without asplenia or hyposplenia, although the small number of patients included limited our power to detect potential differences between groups.
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Affiliation(s)
- Damien Contou
- Service de réanimation polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-Colonel Prud'hon, 95100, Argenteuil, France. .,Groupe de recherche clinique CARMAS, Université Paris Est Créteil, Créteil, France.
| | - Rémi Coudroy
- Service de réanimation médicale, Centre Hospitalier Universitaire de Poitiers, 2 Rue de la Milétrie, 86021, Poitiers, France.,INSERM CIC 1402, ALIVE Group, Université de Poitiers, Poitiers, France
| | - Gwenhaël Colin
- Service de réanimation médico-chirurgicale, Centre hospitalier départemental de Vendée, Boulevard Stéphane Moreau, 85925, La Roche-sur-Yon, France
| | - Jean-Marc Tadié
- Service de réanimation médicale, Centre Hospitalier Universitaire de Rennes, 2 rue Henri le Guilloux, 35033, Rennes, France
| | - Martin Cour
- Service de réanimation médicale, Hospices Civils de Lyon, Groupement Hospitalier Edouard Herriot, 3 quai des Célestins, 69002, Lyon, France
| | - Romain Sonneville
- Service de réanimation médicale, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, 46, rue Henri Huchard, 75877, Paris Cedex 18, France
| | - Armand Mekontso Dessap
- Groupe de recherche clinique CARMAS, Université Paris Est Créteil, Créteil, France.,Service de réanimation médicale, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France
| | - Nicolas de Prost
- Groupe de recherche clinique CARMAS, Université Paris Est Créteil, Créteil, France.,Service de réanimation médicale, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51 Avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France
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The authors reply. Crit Care Med 2019; 47:e1040. [PMID: 31738266 DOI: 10.1097/ccm.0000000000004063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Klifto KM, Gurno CF, Grzelak MJ, Seal SM, Asif M, Hultman CS, Caffrey JA. Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis. BURNS & TRAUMA 2019; 7:30. [PMID: 31641673 PMCID: PMC6798408 DOI: 10.1186/s41038-019-0168-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/06/2019] [Indexed: 12/29/2022]
Abstract
Background Cutaneous manifestations of purpura fulminans (PF) present many challenges for clinicians and surgeons. In a state of septic shock complicated by limb ischemia, surgical interventions are necessary to control the pathological cascade and improve patient outcomes. The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults. Methods This systematic review and meta-analysis compared 190 adult patients with etiologies, signs and symptoms, and surgical outcomes associated with cutaneous manifestations of PF. The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical interventions, outcomes, and complications were recorded. Results Seventy-nine studies were eligible for the systematic review, and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. A total of 71/190 (38%) cases reported surgical debridement. Fasciotomies were reported in 12/190 (6%) cases and 20 procedures. Amputations were reported in 154/190 (81%) cases. Reconstruction was reported in 45 cases. Skin grafts were applied in 31 cases. Flaps were used for reconstruction in 28 cases. Median (IQR) surgical procedures per patient were 4 (4, 5) procedures. Infectious organisms causing PF were 32% Neisseria meningitidis (n = 55) and 32% Streptococcus pneumonia (n = 55). Coagulase-negative Staphylococcus (95% confidence interval (CI)(8.2-177.9), p = 0.032), Haemophilus influenza (95%CI (7.2-133), p = 0.029), Streptococcus pneumonia (95% CI (13.3-75.9), p = 0.006), and West Nile Virus (95%CI (8.2-177.9), p = 0.032) were associated with significantly more extensive amputations compared to other organisms. Conclusion This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism. Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF. The majority of cases were not treated in a burn center. The most common surgeries were amputations, with below-the-knee-amputations being the most common procedure. Skin grafting was the most commonly performed reconstructive procedure. The most common complications were secondary infections. Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus, Haemophilus influenza, Streptococcus pneumonia, and West Nile Virus. Interpretation of findings should be cautioned due to limited sample data.
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Affiliation(s)
- Kevin M Klifto
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Caresse F Gurno
- 2The Johns Hopkins University School of Nursing, Baltimore, MD USA
| | - Michael J Grzelak
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Stella M Seal
- 3Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Mohammed Asif
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - C Scott Hultman
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
| | - Julie A Caffrey
- 1Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD USA.,Johns Hopkins Burn Center, 4940 Eastern Avenue, Baltimore, MD 21224 USA
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Diagnostic yield of lumbar puncture in adult patients with purpura fulminans. Intensive Care Med 2019; 45:1487-1489. [PMID: 31278443 DOI: 10.1007/s00134-019-05676-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2019] [Indexed: 10/26/2022]
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Labroca P, Chiesa G, Laroyenne I, Borrini L, Klotz R, Phan Sy Q, Cristina MC, Martinez AB, Bollaert PE, Paysant J, Lemarié J. Quality of life assessment following amputation for septic shock: a long-term descriptive survey after symmetric peripheral gangrene. J Crit Care 2019; 53:231-235. [PMID: 31277050 DOI: 10.1016/j.jcrc.2019.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess health-related quality of life (HRQOL) following rehabilitation of amputees suffering symmetric peripheral gangrene (SPG) after septic shock. MATERIAL AND METHODS A retrospective cohort study was conducted in nine French specialized rehabilitation centers. Thirty-two ICU adult patients hospitalized between 2005 and 2015 for septic shock who additionally presented with SPG resulting in at least two major amputations were enrolled. HRQOL was assessed by EQ-5D-3 L questionnaire. RESULTS All patients (mean ICU length of stay 39 ± 22d, SAPS II 58 ± 18) had both lower limbs amputated and 84% were quadruple amputees. HRQOL, assessed 4.8 ± 2.8 years after amputation, was inferior to the French reference. However, patients' self-rated health status was similar to the reference at the time of HRQOL assessment. The main factor of impaired HRQOL was intense phantom pain, not the mobility or self-care dimensions of EQ-5D. All patients except one preferred to be treated again for SPG despite disability. CONCLUSION ICU survivors referred to rehabilitation centers after SPG-related amputations had impaired HRQOL. At the time of HRQOL assessment, they considered themselves in good health and preferred to be treated again despite disability. Appraisal of long-term functional outcome should not be used to guide end-of-life decision-making in this situation.
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Affiliation(s)
- Pierre Labroca
- Réanimation médicale, hôpital central, C.H.R.U. de Nancy, Nancy, France
| | - Gérard Chiesa
- Service de rééducation et d'appareillage, Institut Robert Merle d'Aubigné, Valenton, France
| | - Isabelle Laroyenne
- Service de médecine physique et de réadaptation, Centre Médico-Chirurgical de Réadaptation des Massues, Lyon, France
| | - Léo Borrini
- Service de médecine physique et de réadaptation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Rémi Klotz
- Service de médecine physique et de réadaptation, centre de médecine physique et de réadaptation de la tour de Gassies, Bruges, France
| | - Quoc Phan Sy
- Service de médecine physique et de réadaptation, Hôpital la renaissance sanitaire, Villiers-Saint-Denis, France
| | | | - Anne Brunon Martinez
- Service de rééducation réadaptation, Hôpital Universitaire du Grau du Roi, Le Grau du Roi, France
| | | | - Jean Paysant
- Centre Louis Pierquin, Institut Régional de Médecine Physique et de Réadaptation, Nancy, France
| | - Jérémie Lemarié
- Réanimation médicale, hôpital central, C.H.R.U. de Nancy, Nancy, France.
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Yamamoto S, Ito R. Acute infectious purpura fulminans with Enterobacter aerogenes post-neurosurgery. IDCases 2019; 15:e00514. [PMID: 30911465 PMCID: PMC6416646 DOI: 10.1016/j.idcr.2019.e00514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 02/25/2019] [Accepted: 02/25/2019] [Indexed: 12/03/2022] Open
Abstract
Acute infectious purpura fulminans (AIPF) is a rare, life-threatening disease commonly caused by Neisseria meningitidis and Streptococcus pneumoniae. Gram-negative rods are rarely involved. We described a case of AIPF associated with Enterobacter bacteremia in a 48-year-old man admitted for subarachnoid hemorrhage treatment. After surgical clipping for intracranial aneurysms, septic shock, multiple organ failure, and extensive purpura on the skin developed. Enterobacter aerogenes bacteremia was detected and AIPF was diagnosed. His condition progressively worsened and he died on day 19. Autopsy showed multiple abscesses and thrombosis in the lung, intestinal tract, and kidney.
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Affiliation(s)
- Shinya Yamamoto
- Corresponding author at: Department of General Internal Medicine, Shonan Kamakura General Hospital, Kamakura, 247-8533, Japan.
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